Technical Data Collection and Reporting

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Should all Article 28 hospitals, psychiatric facilities and clinics report patients?
All hospitals should report patients in inpatient settings. This includes psychiatric inpatient hospitals and units within hospitals but excludes ambulatory clinics.

What variables will be used for risk adjustment and co-morbidity (e.g., age, race, etc)?
We will be using a number of demographic variables, in addition to the severity and co- morbidity variables as defined in the dictionary. The risk adjustment model will be shared at a later date.

For alphanumeric fields (e.g., 15) do we pad with spaces or simply submit UP to 15 characters?

Submit up to 15 characters. There is no left padding.

Will the Department provide a grid for chart abstraction? Will CSV files be accepted?
Data will not be collected using form or grid methods but will be accepted using more current data collection methodologies such as NHSN data submission. Data will be accepted as a standard data file (e.g., a CSV file) which may be submitted as a batch of data or as a single case upload.

Will hospitals be provided a snapshot of the data collection tool used to submit data for the sepsis initiative? Will we be submitting patient level results on every patient for each data element in the sepsis date dictionary or aggregate data?
There is no data collection tool; per se. Data will be collected as a file to match formatting specified in the data dictionary. Yes, the Department is collecting patient level data which is not aggregated by the hospital prior to submission.

Within a hospital, who should be responsible for collecting the required data?
That decision is left to each hospital however, in conversation with your colleagues; we have found that many hospitals are working with staff across several departments to collect data (e.g., infection prevention, information services, pharmacists, etc). For example, the information services department may be able to pull administrative or electronic health record data to assist the clinical department(s) in their efforts to complete all of the required data elements. Other hospitals may be working to alter health data systems to capture all required data elements within their electronic health record.

What if the patient name is too short? What are the specific date requirements? How long is the field for a particular data element?
Each data element is specified in detail in the data dictionary. Within the dictionary, you will find examples for more complicated situations such as a short patient name, missing social security numbers, actual variable sizes and types. The dictionary will be the definitive source for data specification. Please consult https://ny.sepsis.ipro.org/ to ensure you have the most current version of the data dictionary.

What do we submit if we do not have cases for a quarter? Are we required to upload a blank file to indicate that we have met reporting requirements?
The Sepsis Data Portal website has a section to attest to reporting zero sepsis cases for your hospital for the reporting period.

Does the DOH mandate that we report through their data collection site?
Yes, as per Department regulation, Article 28 hospitals will be required to submit data for their severe sepsis and septic shock patients. This data must be reported via the Department designated data collection portal.

Will the abstraction tool require clinical judgment or can it be completed by administrative staff? 
There is no data collection tool. Data will be collected as a file to match formatting specified in the dictionary. There will certainly be clinical judgment required, although the data may be collected retrospectively, prospectively, or concurrently. Your IT/IS department may need to be involved in regards to extracting the data for transfer as a file. In the dictionary, you will see fields that are patient specific so there are patient level requirements. It is anticipated that hospitals will find it easier to send all of the cases as a batch file rather than individually uploading each case. More information was provided during the webinar on April 29, 2014, which was recorded. A link to the recorded webinar is available at https://ny.sepsis.ipro.org/. It is not necessary to login to download and/or view materials.

When will we receive data/reports back? Will we be able to produce reports summarizing adherence rates and outcomes?
It is expected that data will be provided to hospitals on a quarterly basis, post data analysis. The risk-adjusted mortality and process measure results will take longer to produce.

Will DOH/IPRO be creating a new report from our corrected data if we identified an error?

Data submissions are 'frozen' at set times for report production of quarterly results. Therefore, prior quarterly data will not be recalculated however; aggregated cumulative data (e.g., year to date, annual, etc) will capture corrected data. It is important that corrected data be submitted as soon as possible since cumulative aggregate reporting will include these corrected data.

Is the raw mortality score eventually going to be weighted?

Decisions on analysis of mortality are still in process however a risk-adjusted mortality is planned.

If a patient was treated for severe sepsis in an acute care facility and then discharged from the acute care facility and admitted to a hospice bed in the same facility (which is a contracted service, a new encounter with a different account number), is it necessary to reenter the same patient into the database for this second encounter when no elements of the protocol (no IV, no antibiotic, no blood draws as per advance directives) are being implemented?
The full care for the severe sepsis or septic shock episode, regardless of the hospital unit for which the patient may have presented during the stay, should be reported. For example, if the severe sepsis was identified and treatment begun in the psychiatric unit of your hospital then you also want to report the care provided in that unit in addition to the continued care in a different unit of the same hospital. The case should not be reported again. Transfer status will be reported as 1=Not a Transfer-Patient was neither admitted as a transfer nor, discharged as a transfer to/from a different acute care hospital.

Where can I obtain a list of all hospitals' PFI numbers?

A link to determine PFI's is available on the data portal web site under 'Help Center and Documentation'; it is listed in the data dictionary; and list at: http://www.health.ny.gov/statistics/sparcs/reports/compliance/alpha_facilities.htm

If a patient is moved from one area of the hospital to another i.e., from the Emergency Department to the ICU should this be reported as a Transfer?
No. This patient is not considered a transfer. Only if the patient is moved between different hospitals, with discharge and admission at each location, and separate billing from each location, is the case considered a transfer.

If a patient is moved from one area of the hospital to another within the same hospital system i.e., from the Psychiatric Unit to an inpatient medical floor should the case be reported twice.
No. Only cases transferred between hospitals should be reported separately by each separate hospital. Cases transferred between units or floors of the same hospital should be reported as a single case(s) with the full hospital care reported in its entirety.

If a protocol is initiated in the ER by the ICU team prior to transfer, do we report "Protocol Initiated Place' as the ER or the ICU?
You should report 'Protocol initiated in the emergency room'. The protocol initiated place is the physical location of the patient when the protocol was initiated.

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